Friday, September 13, 2019

This addresses concerns that folks who had become eligible for an SEP but unable to finalize a new plan because of storm-related issues will get another bite at the apple:

"Consumers who qualified for an enrollment period, such as an SEP, but were unable to complete a Marketplace application, plan selection, or enrollment process due to Hurricane Dorian, may have access to an Exceptional Circumstances SEP."

They get an extra 2 months (well, 60 days) to log in and enroll, and "request a retroactive start date based on when he or she would have picked a plan if not for Hurricane Dorian."

Thursday, September 12, 2019

Back on August 31, we purchased a new oven from our local Lowe's store (wanted to support the local folks instead of ordering online). That proved to be a mistake.

We were promised delivery by today (September 12), and that was the last we heard from them.

No follow-up, no notification, nothing.

So I called the store this morning, and was informed that the delivery had been pushed out to the 22nd.

Again, no one bothered to communicate this to me. I only learned of it because I initiated the call. I told the manager that this was not acceptable, and that I expected delivery today. He insisted several times that he couldn't promise that. No effort was made to accommodate or offer alternatives.

So I called corporate, and was informed that the oven had been delivered to the local store, but because Lowe's store managers are incompetent, I had to learn from the nice lady on the phone that their rule is that they can't send items out for delivery on the same day, and that tomorrow's deliveries are already booked.

To her credit, she reached out to the "delivery coordinator" and promised me that she'd have him contact me directly to makearrangements. I eventually heard back from the coordinator, who was able to move the delivery up to this coming Sunday (Yay!).

So, all's well that ends well?

Not hardly: I should not have had to call them to find out what was happening, and the fact that each person I spoke withhad a different story, is unacceptably poor customer "service."

We havehad been long-time, loyal customers, but no longer.

It's worth noting that other stores, like Home Depot and Best Buy, will generally match Lowe's prices.

Unfortunately, these appear to have been largely ineffectual, and she's now at a very dark place indeed:

"The only treatment that is anticipated to help her is expensive, costing $6000-7,000 per infusion, and the doctor has prescribed 6 infusions to enable her body to reconstitute itself and get her on the road to recovery."

To that end, her family has set up a GoFundMe campaign [full disclosure: I have donated to it] hoping to raise enough money to cover most (if not all) of the expected costs.

Okay, a worthy cause, but why isn't her insurance company covering it (or at least most) of it)?

Well, that's because the carrier, Aetna, "has refused to pay for the treatments, calling the drug "experimental" and providing no recourse for her worsening condition."

Seems familiar, no?

[ed: for the purposes of this post, we'll table discussion of an insurer's putative responsibility to offer alternative treatment suggestions]

As noted in the GFM, there have been appeals and advocates, apparently to no avail.

As a parent and husband myself, I can certainly sympathize with the family's plight, but I have some questions.

So I've reached out to both Sarah's family and her insurance company, and would like to share what I've learned:

Her father, who was very nice and forthcoming, had no direct knowledge of the plan's details. He in turn put me in touch with his son-in-law (whose employer's coverage is the insurance at issue). Unfortunately, he has yet to respond (I'll update the post if/when he does).

In the meantime, I also reached out to Aetna:

"Good morning!

We're working on a post about [the GoFundMe], and would like to have Aetna's side, as well. We understand that you can't comment about this case specifically, but would be interested in speaking/emailing with a claims person who can address the dynamic between experimental vs medically necessary treatments.

Looking forward to hearing from you."

About which co-blogger Bob gently prodded me:

"Still tilting at windmills?

Carriers RARELY set their own standards for medical necessity, experimental, provisional. Much easier to follow CMS guidelines as in "it's not my fault, this is how Medicare handles it."

Doubt you will get very far with this, even without factoring PHI complexities."

I knew that he was right, but "in for a penny...."

In the event, I did, in fact, hear back from them:

"Hi Henry:

My name is Ethan Slavin and I work in the Communications department at Aetna. While we can’t comment on this specific situation (as you noted), we can provide you with our general overview on how we make coverage decisions.

You are welcome to use information from this page for your post, as you see fit.

Please let me know if you have any questions."

Which was not unexpected, and actually helpful.

I would still like to know whether or not the plan in question is self-funded (because that could make a difference), but the reality is that Bob's correct, and while sad, this is pretty standard, and not subject to online petitions and the like.

Again, I'd ask why the venom is being directed at Aetna and not the folks with the high-priced meds, or the providers who would administer them.

[Full disclosure: I am not active in the Medicare Supplement/Advantage market]

Recently received this in email:

"New for 2020: Lasso Medicare Savings Account Plan"

Medicare MSA's appear to be the post-65 version of what we typically see as Health Savings Accounts (HSAs) in the pre-65 market, with some interesting twists:

• $0 Premium• MSAs are one type of Medicare Advantage (MA) plan that the Centers for Medicare and Medicaid Services (CMS) partners with private insurance companies to offer. MSAs combine a high deductible health plan covering Medicare A/B expenses with an IRS-approved trust/ custodial savings account. • No admin/monthly fees for MSA account while beneficiary is on plan• See any provider or hospital that excepts [sic] Medicare!• Individual must enroll in a stand-alone [Part D Rx Plan]. • HSA account funds can transferred into new MSA accounts. • Plans are available in every county in the states where they are available [ed: go figure].

I checked with co-blogger Bob V (who's very active in the Medicare market) and he confirmed that the idea is legit.

This particular iteration is intriguing, since the vendor, not the insured, is making the actual deposit. Once that's made into the insured's account, it's immediately vested, and can be used for medical-related items (like doctors' visits and rx co-pays). Since it's 100% the insured's money, there's definitely some 'skin in the game,' and we can see that in action:

"[A]s of September 1, 2019, 81% of all Lasso Healthcare MSA plan members had spent less than $1,000 in their current benefit period!"

Hunh.

[ed: I reached out to see if the insured/beneficiary could also contribute to the account, and will update this post if/when they reply]

Currently, the Lasso plan is available in over 25 states (almost half of them!).

"The owners ... have blamed their insurers for a lawsuit that they filed to limit their payouts to victims' families, calling it an "unfortunate side of these tragedies."

Oh sure, blame the insurer.

On the other hand, it's the insurer's duty to its policyholders and owners (stockholders) to limit those damages, and that's why they keep lawyers on hand for just this kind of situation. It does seem rather crass, but the insurer is also bound to do all it can to mitigate the damages. And the timing, while unfortunate, may have little to do with lack of compassion, and much to do with timely filing.

Our hearts, of course, go out to those families, but this seems to be strictly business.

To be sure, there are still quite a few other permanent-type plans out there with the same issue.

And what issue is that, Henry?

Well, when these plans "mature" while the insured is still alive, that person is likely to be hit with a pretty hefty tax bill; that is, the policy is paid out as a lump sum to the insured, and any excess over the total premiums paid are taxable. That could be a sizeable sum indeed, and is a double whammy (since that policy is now canceled).

Until now, there really wasn't much one could do about in-force plans (hence the clarion call for a class action lawsuit).

But in a Long Term Care insurance (LTCi) product training session last week, I learned about another product that might be a solution to the tax issue:

OneAmerica Life offers an annuity product that's available to folks up to 99 years old, and doesn't require forced annuitization (or Required Minimum Distributions). While marketed as a potential LTCi alternative, it struck me as solving at least part of that "maturation" problem, since there's no immediate funds to pay out and thus be taxed. Called "Legacy Care®," it lets one roll-over the cash value of an existing life insurance policy and continue to defer taking the tax "hit" (although it's going to fall to one's heirs eventually).

Not perfect, of course, but at least a little light at the end of the tunnel.

An actuary on the staff at the National Association of Insurance Commissioners is wondering whether, and how, the existence of nonbinary people might affect the world of life insurance.@naichttps://t.co/w66AR7pAhd

It's silly because (for starters) trans/other Americans comprise barely a rounding error of the general population. Actuaries, by definition, work with very large groups, not infinitesimally-small ones, which would yield an essentially meaningless sample.But wait, it gets "better:"Actuaries estimate "probability of risk," that is, the likely number of expected deaths from a (again, large) population; it's merely a pricing tool.The only opinion that matters here is the underwriter's, because his job is assessing the specific risk, and then deciding whether or not it's acceptable, and at what premium (rating factor).In the event, neither of these folks would ever even see such an application in the firstplace, for a very simple reason: all life applications require one to provide name, socialsecurity number, date of birth, and sex (among other things). Applications missing this information will be returned to the agent for completion.There's also the small problem of the "misstatement of age or sex" clause, which would come into play at claim time.But even more important, from that underwriter's point-of-view, is this:"As I discussed with a life field rep friend a while back, the life company is likely to decline the case altogether because of the increased suicide risk."By the way, these issues would also come into play with auto, disability income, long term care and other types of insurance, as well. Which means a lot of wasted time for a trifle.Talk about much ado ....

Why would lawmakers be interested in making these prices transparent,
since the only time you would use an Air Ambulance is in an Emergency?

Because customers have received “surprise air ambulance bills …from insurers that have denied
claims for emergency transport, saying the rides weren't preauthorized or weren't necessary.”

I have seen my share of unwarranted
denials, but this takes the cake. In an emergency there is no time to get a
Preauthorization. A Preauthorization is usually required for any type of
surgery, lab, test, or medication that will require a significant reimbursement
by an insurer. Preauthorization’s can take anywhere from 48 hours to weeks to
obtain. Obviously if you are bleeding on the side of the road and will die
without immediate medical coverage you cannot wait for a Preauthorization.

As to the necessity, once again, it
is self-evident.

It is this idiocracy of thinking by
insurance companies that hinder medical decision making. While this is an
extreme of insurance meddling in medical decision making, this interference
occurs hundreds of times a day in every medical facility across the nation.

Josh Wilkerson had recently come off of his stepfather's health insurance (he had reached that magical age of 26) and had elected not to buy his own. As usual, the reporter doesn't bother to ask why Mr Wilkerson chose to "go bare;" at his age a catastrophic ACA plan would have cost about $300 a month (assuming he didn't use tobacco). At least one plan appears to cover insulin.

Be that as it may, the high cost of "regular" versions of the med have become quite expensive, which is a problem for any number of reasons, not the least of which is this:

How we got here is outside the scope of this post, but there appears to be more than enough blame to spread around.

So what is the point of this post, you ask?

Well, it's actually quite simple (for certain values of "simple"):

Regardless of how we got here, it's a big problem, so how do we fix it?

Of course, many folks would have the government wave its magic wand and legislate that it be covered at little or no expense (for those who are insured) or provided at little or no cost (to those who are not).

Which seems reasonable on its face, until one considers this:

3/3 I'm expecting their next proclamation to involve insulin for all diabetics, as Schedule "A" wellness. This will really beat up your health insurance, the math is staggering.30.1m people x $1,200/month average = $433 Billion in new health insurance premiums to be paid.